Hospice Documentation Checklist

A CMS Medicare Administrative Contractor

MEDICARE

Hospice Documentation Checklist

Claim Information

Initial DOS: SOC:

Documentation of Beneficiary Election

An individual (or his/her authorized representative) must elect hospice care to receive it. The initial

election is for a 90-day period. An individual may elect to receive Medicare coverage for two 90-day

periods and unlimited number of 60-day periods. If the individual (or authorized representative) elects

to receive hospice care, he or she must file an election statement with a particular hospice. Hospices

obtain election statements for the individual and file a Notice of Election (NOE) with the Medicare

Contractor, which transmits to the Common Working File (CWF) in electronic format. Once the initial

election is processed, CWF maintains the beneficiary in hospice status until a final claim indicates a

discharge (alive or due to death), or until an election termination (revocation) is received.

Identification of which hospice will be providing care

YES

NO

Beneficiary Election Statement

Beneficiary acknowledgement of palliative versus curative treatment is on the statement of election

Beneficiary acknowledgement of waiving traditional Medicare benefits to elect hospice

YES NO YES NO

The effective date the beneficiary or representative wants the hospice YES

election to begin

NO

Designated attending physician (if the beneficiary has one), with

YES

enough information to identify the physician (i.e., office address, office NO phone #, NPI).

*note ? beneficiary is not required to have an attending physician

Beneficiary acknowledgment statement the attending physician is the YES

beneficiaries choice

NO

Beneficiary or authorized representative has signed and dated the NOE. Best practice tip: State the date, so the beneficiary/representative

YES NO

writes the correct date.

National Government Services, Inc. 1522_0120

HOSPICE DOCUMENTATION CHECKLIST

Documentation of Physician Certification of Terminal Illness (CTI)

The Initial Certification is the first 90-day period of hospice coverage. For Medicare payment, the initial

certification must contain two physician signatures if the beneficiary has designated an attending

physician. The beneficiary is not required to have an attending physician in order to participate in the

Medicare hospice benefit. There is only one initial certification period (the first 90-day period of hospice

coverage). All other benefit periods are called subsequent benefit periods.

Note: a hospice agency or documentation vendor may request as part of their internal policy that two

physician signatures are obtained at the start of care for each benefit period. This is not a Centers for

Medicare & Medicaid Services (CMS) mandate, it is an internal policy. See the Centers for Medicare &

Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy

Manual, Chapter 9, Section 20.1 for an initial certification period.

Was the initial physician certification of terminal illness (CTI)

statement signed by the attending (if applicable) and the hospice medical director or a hospice physician member of the IDG within

YES NO

two days of care being initiated (that is by the end of the third day),

but no earlier than 15 days prior to the certification period?

*note - a hospice attending physician is the beneficiaries choice and

the beneficiary is not required to have an attending physician.

Did you document a verbal certification if the written CTI was not

Initial

signed within two days of admission (that is by the end of the third day)?

YES NO

Certification Did the physician(s) sign and date their signature on the CTI?

YES NO

of Terminal Does the CTI contain the benefit period dates (from and thru date)

Illness (CTI) on the certification?

YES NO

Example: 01/11-XX through 04/10/XX

Does the CTI contain a brief physician narrative?

Note: The physician narrative must contain specific clinical findings YES NO

that supports a life expectancy of less than six months.

Does a statement appear directly above the physician signature

attesting that by signing, the physician confirms that he/she

YES NO

composed the narrative?

Does the CTI contain a statement that the individual's medical

prognosis is six months or less should the disease run its normal

YES NO

course?

National Government Services, Inc. has produced this hospice documentation checklist as an informational reference guide to assist providers furnishing hospice services in our contract jurisdiction. National Government Services does not imply that use of this checklist will guarantee payment.

HOSPICE DOCUMENTATION CHECKLIST

Subsequent Physician Certification Terminal Illness (CTI)

A subsequent certification period, is any certification period that occurs after the initial 90-day election period of hospice care. Subsequent certifications may be completed up to 15 days before the next benefit period begins, but no later than two calendar days (that is by the end of the third day) after the first day of each period. The hospice must obtain written certification of terminal illness for

each benefit period, even if a single election continues in effect Example: Admitted Friday, January 3rd December 19th (15 days prior) is the earliest the oral or written certification can be obtained. Must have an oral or written certification signed by the end of Sunday, January 5th (two days after the benefit period). Oral or written certification signed prior to December 19th or on and after Monday, January 6th are untimely.

Subsequent CTI

Was the recertification statement signed by the hospice medical director or a hospice physician member of the IDG? Was the CTI signed and dated within two days (by the end of the 3rd day) of the certification period but no earlier than 15 days before the certification period?

Does the CTI contain the benefit period dates (from and thru date) on the certification?

Example: 01/11-XX through 04/10/XX Does the CTI contain a physician narrative? Note: The physician narrative must contain specific clinical findings that supports a life expectancy of less than six months. Does a statement appear directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative? Does the CTI contain a statement that the individual's medical prognosis is six months or less?

Does the CTI contain a FTF (if a third or later benefit period) or a separate FTF addendum (if a third or later benefit period)?

YES NO YES NO

YES NO YES NO YES NO YES NO YES NO

National Government Services, Inc. has produced this hospice documentation checklist as an informational reference guide to assist providers furnishing hospice services in our contract jurisdiction. National Government Services does not imply that use of this checklist will guarantee payment.

HOSPICE DOCUMENTATION CHECKLIST

Oral Certification

CMS requires a written certification of terminal illness within two days (that is by the end of the third

day), in order for a beneficiary to be eligible to elect hospice. If your agency is unable to obtain a

written certification, then an oral certification must be documented in the medical records with two

days (that is by the end of the third day). An oral certification is an interim certification until a written

certification can be obtained. Once the oral certification is obtained and documented in the medical

record, you have until you bill Medicare to obtain the written certification. You may not bill Medicare

without a valid signed written physician certification of terminal illness.

Obtain within two calendar days after care was initiated and

documented in the medical record when a written certification was not

Oral Certification

obtained within two days. Example: admission date of February 4th must be signed by the end of the third day ? which is February 6th.

YES NO

Documentation identifying the physician giving the oral certification YES NO

Statement that the individual's medical prognosis is six months or less

YES NO

Signed and dated by author

YES NO

National Government Services, Inc. has produced this hospice documentation checklist as an informational reference guide to assist providers furnishing hospice services in our contract jurisdiction. National Government Services does not imply that use of this checklist will guarantee payment.

HOSPICE DOCUMENTATION CHECKLIST

Face-to-Face Encounter (if applicable)

Required with all third and later benefit periods

A face-to-face (FTF) is required for all beneficiaries entering their third or later benefit period. A

hospice physician or hospice nurse practitioner must have a FTF encounter with each hospice

patient. The encounter must occur prior to the recertification for the third benefit period and each

subsequent benefit period. The encounter must occur no more than 30 calendar days before the third

benefit period recertification and each subsequent recertification. Failure to meet the FTF encounter

requirements specified, results in a failure by the hospice to meet the patient's recertification of

terminal illness eligibility requirement.

Example:

Start of the benefit period: 01/31/20XX. Thirty days prior ? cannot occur any earlier than January 1,

XX.

May be performed on the first day of the next benefit period and still be timely, which is January 31,

XX in this example.

FTF Timeframe - Was timeframe of the encounter met? The FTF can occur no earlier than 30 days prior to the start of the

YES NO

benefit period up to and including the first day of the start of the

benefit period.

Attestation of FTF Encounter - Did the noncertifying hospice

YES NO

physician or hospice nurse practitioner attest in writing that he or she

had a FTF encounter with the patient and include the date of the

FTF?

FTF Encounter

Attestation of Results - Is there an attestation that the results were given to certifying physician? Note: The attestation must state that the clinical findings of that visit were provided to the certifying physician.

FTF Titled - Is the FTF clearly titled as the FTF in either a separate and distinct area of the CTI or as a separate addendum?

YES NO YES NO

Note: the FTF must be clearly titled the FTF and contain the FTF

encounter date

Physician Narrative - Is the physician narrative documented?

YES NO

The narrative must reflect the patient's individual clinical

circumstances and cannot contain check boxes or standard

language used for all patients. The physician must synthesize the

patient's comprehensive medical information in order to compose

this brief clinical justification narrative. The physician must sign and

date their documentation.

National Government Services, Inc. has produced this hospice documentation checklist as an informational reference guide to assist providers furnishing hospice services in our contract jurisdiction. National Government Services does not imply that use of this checklist will guarantee payment.

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